PRINCIPLES OF ULTRASOUND GUIDED

MUSCULOSKELETAL INTERVENTIONS
Jonathan Finnoff, DO
Tahoe Orthopedics and Sports Medicine
Director of Sports Medicine, Barton Health
South Lake Tahoe, CA
 Disclosures
I have no financial disclosures
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Objectives
Definition
Why US-guidance?
General Principles
Indications & contra-
indications
Equipment
Set-up
Technique
Pitfalls & Pearls
Conclusion

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What Are We Talking About?

Direct Ultrasound Guidance

Real time US visualization to guide the needle to the target
area safely and efficiently
Targets
Joints & Bursa
Muscles
Tendon sheaths
Masses
Perineural

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Why US Guidance?

(Haig et al. Arch Phys Med Rehabil 2003)

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Why US Guidance?

(Goodmurphy et al. J Clin Neurophysiol 2007)

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Why US Guidance?

(Goodmurphy et al. J Clin Neurophysiol 2007)

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Why US-guidance?

(Boone et al. Muscle Nerve 2011,

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Why US-guidance?
Accuracy US Palpation Fluoro
GH joint 95%1 79-83%1,4
SA-SD bursa 100%1 63%1 60%2
AC joint 100%1,3 40-67%1,3,4
Knee 96-100%1,5,6 55-79%1,5,6
BT Sheath 100%7 66.6%7
PIP & MCP jts 96%8 59%8
Inf Arthritis Jt Injs 83%9 66%9
GH Jt 1st try 94%10 72%10

(1Daley EL AJSM 2011, 2Mathews PV J Shoulder Elbow Surg 2005, 3Peck E PMR 2010,
4Partington PF J Shoulder Elbow Surg 1998, 5Park YB J Clin Ultrasound 2011, 6Curtiss HM

PMR 2011 7Hashiuchi T J Shoulder Elbow Surg 2011, 8Raza K Rheumatology 2003,
9Cunnington J Arthritis & Rheumatism 2010, 10Rutten MJ Eur Radiol 2009)
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Why US-guidance?
Accuracy US Palpation CT
Per. Ten. Sheath1 100% 60%
Piriformis2 95% 30%
Pes Ans. Bursa3 92% 17%
Lumbar facet jts4 100% 100%
STT jt5 100% 80%
Flex. Ten. Sheath6 70% 15%
Tibiotalar jt7 100% 85%
Sinus Tarsi7 90% 35%

(1Muir JJ Am J Phys Med Rehabil 2011, 2Finnoff JT J Ultrasound Med 2008, 3Finnoff JT PMR
2010, 4Galiano K Reg Anesth Pain Med 2007, 5Smith J J Ultrasound Med 2011, 6Lee DH J
Ultrasound Med 2011, 7Wisniewski SJ PMR 2010)
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Why US-guidance?
Mathews et al. evaluated the accuracy of anterolateral and
posterior palpation-guided SA-SD bursa injection
approaches.
Used fluoro followed by dissection to confirm injectate
location
Fluoro suggested accuracy rate of 90% for anterolateral
approach, but dissection revealed only 60% were actually
accurate
Take home point = fluoro couldnt accurately determine
whether the injectate was or was not in the SA-SD bursa

(Mathews et al. J Shoulder Elbow Surg 2005)

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Why US-guidance?
Efficacy US-guided Palpation-guided
SA-SD Bursa1 VAS 4 VAS 2
Greater ROM
SA-SD Bursa2 VAS 34.9 VAS 7.1
SFA 15 SFA 5.6
SA-SD/GH Jt 3 4 x greater benefit than palp guided
SA-SD Bursa4 NRS 1.6 NRS 3.3
Good resp 81% 54%
SA-SD Bursa5 Signif abd ROM No in ROM

(1Ucuncu F Clin J Pain 2009, 2Naredo E J Rheumatol 2004, 3Eustace JA Ann Rheum Dis
1997, 4Zufferey P J Bone Spine 2011,5Chen MJL Am J Phys Med Rehabil 2006)
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Why US-guidance?
Efficacy US-guided vsPalpation-guided
Knee 48% less procedural pain1,2
42% more pain reduction1
183% more fluid aspirated2
107% more responders1
52% less non-responders1
Carpal Tunnel3 77.1% less procedural pain
63.3% more pain reduction
84.6% more responders
51.6% less non-responders
71% longer pain relief
(1Sibbitt WL J Clin Rheumatol 2011, 2Sibbit WL Scand J Rheumatol 2011, 3Chavez-Chiang
NR Arth Rheum [S] 2010)
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Why US-guidance?
Efficacy US-guided vsPalpation-guided
Infl. Arthritis Inj1 81% less injection pain
35% more pain reduction
38% more responders
34% less non-responders
32% longer pain relief
Infl. Arthritis Inj2 50% greater pain relief

(1Sibbitt WL J Rheumatol 2011, 2Cunnington J Arthritis & Rheumatism 2010)

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Why US-guidance?
Cost Effectiveness US-guided vs Palpation-guided
Knee1 13% less cost/pt/yr
58% less cost/responder/yr
Carpal Tunnel2 20.8% less cost/pt/yr
59.3% less cost/responder/yr
Infl. Arthritis Inj3 8% less cost/pt/yr
33% less cost/responder/yr

(1Sibbitt WL J Clin Rheumatol 2011, 2Chavez-Chiang NR Arth Rheum [S] 2010, 3Sibbitt WL J
Rheumatol 2011)
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Why US-guidance?
More infections with US-guidance?
NO!
Study compared 402 pts who received IVs with US-
guidance with 402 with palpation-guidance
Palpation infections = 3 = 7.8/1000
US-guidance infections = 2 = 5.2/1000

(Adhikari S J Ultrasound Med 2010)

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Indications For USG

1. When accuracy is important

a) Tibialis posterior
b) Short head of biceps femoris
c) Rhomboids
2. Procedures that normally require
guidance
a) Deep target
b) Difficult to identify target
c) Avoid adjacent structures
d) Diagnostic injections
e) Certain therapeutic injections
3. Assess anatomy
a) Pathology v
b) Variations
4. Soft tissue procedures
5. High risk
a) Lung
b) Neurovascular
c) Anti-coagulation/bleeding d/o
6. Avoid radiation

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Contraindications
General procedural contraindications
US generally safe
Recognize limits
Skills
Equipment
Technique
Unexpected
Masses

v
r/o Bakers Cyst
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Plan Procedure
Ergonomics
Patient lying
Get comfortable
Choose transducer
Linear Array
Superficial structures
Needle angle not steep
Curvilinear Array
Deep structures
Steep needle angle

Schuenke Thieme 2007

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Plan Procedure
Scan area
Identify
Target
Undesirables
Unexpected
Determine needle
approach/path
Doppler needle path
Estimate needle length
Save pre-procedure
image of target
Mark skin

Schuenke Thieme 2007

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General Procedure Set-up
Aseptic technique
Prep skin
Sterile probe cover
Sterile US gel
Ergonomics
See injection site, needle &
machine
Free-hand technique
Non-dominant holds
transducer
Dominant holds needle
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In Plane Approach

Also called:
Long axis
Longitudinal
Needle co-linear with transducer
Visualize tip & shaft
Preferred
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In Plane Approach - Pitfalls
Visualization depends on obliquity

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Out of Plane Approach

Also called:
Short axis
Transverse
Needle perpendicular to
transducer
Appears as dot
Challenging use prn
Superficial joints
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Out of Plane Approach - Pitfalls

Tip Under Tx Tip Past Tx Tip Oblique &

Past Tx
All Look Same
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Out of Plane Approach - Solution
Move tip in & out of field
Walk-down advancement

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Procedure Entry Site

Deeper target requires entry site farther away from

transducer due to effect if obliquity on needle
visualization
Ensure adequate needle length
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Procedure Technique
Cold Spray
Penetrate skin 1 cm
Find needle
Advance real-time
Local anesthesia v
Test trajectory
Hydrodissection

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Procedure Pitfalls & Pearls

1. Anchor transducer!!!
2. Cant see tip dont advance
3. Dont move needle & transducer at
the same time
4. Know when to withdrawal and
redirect
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Needle Visualization In Plane

Strive for parallel

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Needle Visualization In Plane

If cant get parallel, try:

Heel-toe

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Needle Visualization In Plane

Or:
Oblique stand-off

1. Lift one end of Tx

2. Anchor other
3. Fill gap with gel
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Oblique Stand-off: OOP IP

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Needle Visualization In Plane

Needle choice
Length
Size (gauge) matters
but not that much
Echogenic
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Needle Visualization In Plane

Having difficulty finding

your needle tip?
Jiggle
Rotate bevel
Stylet v

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Once You are in the Target

Take a picture with the

needle in the target
Aspirate
Inject under direct US
visualization
Re-scan area to ensure
correct location of
injectate
Consider picture to
document location of v
injectate
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Conclusions

US is a powerful tool for guided interventions in the

MSK system
More accurate and likely more efficacious and cost
effective than palpation guided injections
Visualization of the needle is crucial
In plane approach with minimal obliquity is the goal
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Conclusions
Planning for safe and efficient procedures requires:
Appreciation of basic US physics
Choosing right equipment for the job
Knowledge of anatomy
Skills to find, track, & advance needle
Recognizing limits
This is harder than it looks
Practice is key!!!
Thank you
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References
Bianchi S, Martinoli C. Ultrasound of the Musculoskeletal System.
Springer, New York, pp. 889-918, 2007.
McNally E. Practical Musculoskeletal Ultrasound. Elsevier,
Philadelphia, pp. 283-308, 2005.
Anatomic images were obtained from: Schuenke et al. THIEME Atlas
of Anatomy General Anatomy and Musculoskeletal System. All
rights reserved. THIEME 2007, www.thieme.com